My Opinion: E-Care Is Ethical, Effective, and Economical Care

I make it a general rule not to discuss Intel’s products in this blog, and in so doing, have erred on the side of rarely even mentioning our Intel® Health Guide. Which also means that I haven’t been able to share what our customers are learning as they adopt e-care (electronic care) or telehealth technologies and experiment with new care models. But sometimes the issues are too important not to mention. And I should say that these issues–and the example given below–are not unique to Intel or our product; they are challenges that the whole nascent e-care marketplace faces as we try to enable new care models with new technologies.

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The caller ID on my phone at work showed the same strange area code three times in a row within fifteen minutes while I was on another call. As I Googled the area code to find out where it was from, the same number suddenly showed up on my cell phone. So I answered, looking forward to the opportunity to scream at a telemarketer.

“Eric, sorry to bug you, but I really need to talk to you!” It was a woman I will call “Judy,” the chief nursing officer of a healthcare organization I have worked with for years. She continued, “I’m afraid we may have to end our telehealth program!”

But I had just received a status report a week before that things were going so well for them. “Oh no,” I replied. “What happened?”

She waited so long to respond that I thought we had lost cell signal. Then, she finally stammered out, “I need you to know this. And to shed light on this. But you can’t use my name or my company’s name–I’ll get in trouble. I’m just so frustrated because this is wrong.”

“Judy, what’s wrong?” I asked, as I hung up on my other meeting. Nightmare scenarios went through my head: Had the doctors and nurses doing the electronic visits given up? Did our technology crash somehow? Were they getting negative responses from patients and their family caregivers? But none of these were true.

“We’re scared that we’re hurting our patients. In fact, I know we are–with those patients who don’t have the technology at home because we don’t have any way to know they are getting worse until they show up in the emergency room in a crisis,” she said.

It was my turn to catch my breath. “I’m confused. So you may stop the program because the telehealth patients are doing well?” I asked.

“Yes, too well. We’re only a few months into it, but the data we just got back shows our problem is with the control group, who don’t have the technology in their homes. They are getting worse care–sometimes even dying because of things we think we could have caught with the telehealth data coming in. My nurses are rebelling–they want the technology installed in every patient’s home! They believe it is unethical to continue without giving everyone a system. Honestly, we never realized how different this would be–that we would discover just how bad the old way of doing things really is.”

She went on to explain that there was mounting pressure to remove all of the Intel Health Guides. I asked the obvious question: “So why in the world would you remove the Guides from the patients who have them at home, if both the patients and clinicians love them?”

“Because management is concerned that we’re opening ourselves up to risk if we show that there’s a better way to do care but don’t make it available to all of our ‘frequent flyers.’ Our pilot program is showing us just how blind we are in most of what we do today. But the finance folks are worried that it will be too expensive to provide this access to everyone, so they don’t want to provide it for anyone!” Judy had moved through fear to tears and now anger as she told me all of this.

“But wait…I thought you had already shown that it was cost effective. Why would they be afraid to install these technologies if the economics work out in the long run?” I asked.

“Because they are scared of change. Because revamping our whole care model is hard, even though that’s what my team is funded to do. And because business-as-usual is easier, even, I’m afraid, if it means we’re spending more money and hurting more patients than is necessary! It’s just wrong.”

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I believe e-care is economical, effective, ethical care–sometimes the most ethical care we can provide. Yet there is enormous resistance to adopting these new care models and technologies, even with all the talk of healthcare reform going on. “Judy” is the not the first person to share this kind of story with me. Over the years that we have conducted in-home studies with a wide range of e-care technologies at Intel, I have heard similar narratives dozens of times. And I have met with many other telehealth companies at trade shows and conferences who, quietly and worriedly, share these stories with one another because we are concerned that this market will never reach its potential–and health reform will never really achieve its cost and quality goals–until we change these misaligned incentives, unfounded fears, and misperceptions about e-care.

Some of our critics complain about the economics of telehealth technologies. But we’re not talking about hugely expensive pieces of equipment or software, compared especially to the dollars spent on hospital technologies. We’re talking about providing high quality electronic care at home to complement in-person care at the clinic or hospital through inexpensive and widely available information technologies. These kinds of technologies provide new affordances–monitoring actual vital sign trends, doing quick video visits with patients, providing just-in-time patient education on managing a chronic condition, surveying patients in their homes and at moments where real behavior change occurs–that aren’t available to traditional face-to-face encounters that we hold so sacred, so entrenched, in our policies, payments, and practices.

We’ve all seen nurses and physicians using our technologies quite successfully who then become concerned about the ethics of continuing a pilot because their patients in the control group (without the technology) aren’t doing well by comparison. Clinicians–once trained and comfortable with integrating the technology into their workflow and incentives–don’t want to go back to the “old way” of doing things when the innovative pilot program (often dependent upon grant dollars) is done. Many of them liken telehealth to being given ultrasound or MRI technology for the first time: once you have experienced it, it’s hard to imagine delivering the best care to your patients without such a fundamentally game-changing tool. There is simply no substitute for it.

Skeptics about e-care inevitably ask me, “Isn’t it unethical to interfere with the traditional doctor-patient bond by replacing that with electronic encounters?” But I would ask the question the other way around: Isn’t it unethical to continue treating patients using status quo delivery models when e-care and other new models offer the possibility of better, safer, and even more cost-effective care? What are the ethics of requiring patients to come in for routine labwork or office visits simply because the payment model for doctors requires a face-to-face visit? How ethical–or effective or even cost justified–is it to continue to ask chronic disease and elderly patients–many of whom struggle to find transportation or risk their health by coming into a germ-filled environment–to travel to a clinic for care that can, increasingly, be done from the safety of their own homes? And how ethical, given Judy’s experience, is it to curtail e-care that is really working well because of concerns about risk, exposure, and the challenges of changing clinical practice?

As I travel the world learning about the virtues of electronic care from those in the trenches who are doing it, I also hear from these skeptics–most of whom have never experienced the technology themselves–that telehealth must first “prove itself” through expensive clinical trials and comparative studies with “classic healthcare delivery.” We are told that we must produce a preponderance of evidence that the new care models are better than the “old ways” (even though popular studies show how so few of those ‘old ways’ are based on data or best practice). Somehow e-care is considered “guilty” until proven otherwise.

I believe in evidence-based medicine and the power of randomized clinical trials. But in the case of e-care technologies, my fear is that we’re, most often, just making excuses to perpetuate the status quo because change is so hard. Judy put it well: “Business-as-usual is easier,” so we’ll invent elaborate ways not to change.

I believe we are overly “scientizing” the obvious observation that these technologies can affordably and effectively complement classic face-to-face care in some powerful ways. The studies of tens of thousands of patients show the value of e-care and frankly, we don’t need “further study” and decades and billions of dollars more before implementing e-care models that are already here today. We simply don’t have the time to delay any further, especially when so many people do not have access to any care today, face-to-face or electronic.

How exactly is it that we’re supposed to care for millions of more patients–especially elderly ones–when the capacity of doctors and nurses and the capital needed by society to maintain today’s reactive, clinic-centric care models simply aren’t existent in most parts of the world? We need to accept and embrace e-care as ethical, effective, economical care…and learn to implement these technologies in our best practices in ways we haven’t yet imagined. We need health reform to accept and embrace real change. To do otherwise leaves us all in an ethical and economic quandary that we must overcome.

One Response to My Opinion: E-Care Is Ethical, Effective, and Economical Care

What a thought-provoking post, Eric. It would appear that an unintended consequence of your pilots could be the discovery that the U.S. reimbursement model isn’t the lynch-pin that Berwick proposed. Perhaps Christensen’s hypothesis was closer to the mark. Any change in the status quo of healthcare delivery will challenge stakeholder positions, and will therefore be met with resistance. I hope you publish the outcome of Judy’s dilemma. It will be interesting to see who pays the price for innovation.
Opinions are my own and do not necessarily reflect the views of my employer.

Policy@Intel

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